Encopresis in children

Encopresis is the soiling of underwear stool by children under potty training age. Because each child achieves bowel control at their own pace, health professionals do not consider contaminated stools to be a disease unless the child is 4 years old. These bowel movements or fecal contamination are usually physical and involuntary - the child does not do it on purpose.

It is estimated that 1 to 2% of children under the age of 10 have encopresis. Encopresis affects many more boys than girls; Approximately 80% of affected children are boys.

Causes of encopresis

Rarely, encopresis is caused by an anatomical abnormality or disorder the baby was born with. In the vast majority of cases, encopresis develops as a result of chronic (long-term) constipation.

What is constipation? Many people think that constipation is the lack of a bowel movement every day. However, each person has a different bowel habit, and many healthy people do not have a bowel movement every day. A constipated child may have a bowel movement every three days or less. Constipation is associated not only with infrequent bowel movements, but also with difficulty or pain in doing so.

For most children with encopresis, the problem begins with painful passage of very large stools. This could have happened long before the onset of encopresis, and the child may not remember when asked. Over time, the child refuses to have a bowel movement and holds it back to avoid pain. This "retention" becomes a habit that often persists long after the constipation or pain with passing bowel movements has disappeared.

As more and more stool collects in the baby's lower intestine (colon), the colon slowly stretches (sometimes called a megacolon).
As the colon stretches more and more, the child loses the natural urge to defecate.
Eventually, the softer, partially formed stool from the upper intestine leaks around a large accumulation of harder, more formed stool in the lower colon (rectum) and then exits through the anus (the outward opening of the rectum). body).
Often only a small amount of stool comes out at first, leaving streaks on the baby's underwear. Parents usually assume that the child does not wipe well after a bowel movement and do not worry.
Over time, the child becomes less and less able to hold the stool - the stool leaks more and more, and eventually the child completely defecates in his underwear.
Often the child does not realize that he had a bowel movement.
Because the stool does not pass normally through the colon, it often becomes very dark and sticky and can have a very foul odor.

Over time, a child with encopresis may also develop an incoordination of the muscles used for defecation. For many children, the anal sphincter contracts rather than relaxes when they try to have a bowel movement. This incoordination of muscle function that causes stool retention is a clue to the diagnosis and is also called anismus or paradoxical contraction of the pelvic floor during defecation.

What causes constipation in the first place?

Some experts believe children become constipated when they do not eat enough fiber, available in fruits, vegetables, and whole grain foods.
Many doctors think that some children become constipated because they do not drink enough water.
Constipation does seem to run in certain families.
For many children, no clear cause of the constipation can be identified.

Encopresis is a very unpleasant condition for parents. Many parents are annoyed by the constant desire to wash a dirty child and clean or throw away dirty laundry. Many parents assume that soiling is the result of the child's laziness, or that the child intentionally soils. In most cases, this is not the case. Children with encopresis are no more likely than other children to have serious behavioral or emotional problems.

Symptoms of encopresis

More than 80% of children with encopresis had constipation or painful bowel movements. In many cases, constipation or pain occurred years before encopresis came to the attention of a doctor.

Most children with encopresis say they don't have the urge to have a bowel movement until their underwear gets dirty. Episodes of pollution usually occur during the day when the child is awake and active. Many school-age children get dirty in the afternoon after returning from school. Nighttime pollution is rare.

Many children with encopresis have a twisted colon, so they may occasionally pass very large stools.

When to seek medical care for encopresis

Any of the following require a visit to your child's doctor:

Severe, persistent or recurrent constipation
Pain during bowel movements
Reluctance to defecate, including straining to keep defecation
Contamination in a child who is at least 4 years old

Examinations and tests for encopresis

To diagnose encopresis, your child's doctor will ask many questions about their medical history, potty training history, diet, lifestyle, habits, medications, and behaviors. A thorough physical examination will be performed to evaluate the child's general health, as well as the condition of the colon, rectum, and anus. The doctor may insert a gloved finger into the child's rectum to feel for stool and make sure that the anus and rectum are of normal size and that the anal muscles are of normal strength.

In most cases, blood tests are not part of the diagnosis of constipation and/or encopresis. In some cases, an x-ray of the child's abdomen or pelvis is taken to determine the amount of stool present in the colon and to assess whether the colon and rectum are enlarged. Sometimes an irrigation enema is given. This is a special type of x-ray where a small tube is inserted into the child's rectum and the large intestine is slowly filled with a radiopaque dye (barium). X-rays are taken throughout the procedure to see if areas of narrowing, twisting, or twisting in the small intestine are causing the child's symptoms.

In some cases, anorectal manometry may be performed. In this test, a small tube is inserted into the child's rectum. The tube contains several pressure sensors. During the test, the doctor can determine how the child is using their abdominal, pelvic, and anal muscles during a bowel movement. Many children with chronic constipation and/or encopresis do not use their muscles in a coordinated manner during bowel movements.

The main purpose of manometry is to confirm increased pressure in the anus. Manometry can also show if the nerves that control the anal sphincter, anus, and rectum are present and functioning by measuring reflexes in that area. Manometry measures how distended the rectum is and whether sensation is normal in that area. Abnormal contractions of the pelvic floor muscles can be documented using manometry.

Anorectal manometry may also be useful in ruling out Hirschsprung's disease, a very rare cause of constipation without encopresis. If Hirschsprung's disease is being seriously considered as the cause of your child's encopresis, a rectal biopsy may be needed. A biopsy is the removal of a very small piece of tissue for examination under a microscope. This is done to look for a lack of nerve function in the rectum, which is the hallmark of Hirschsprung disease.

Encopresis treatment at home

Although the parents will follow the diet recommended by the child's doctor, most of the work of treating encopresis is done at home.

It is very important that parents and other caregivers keep a complete record of the child's medication and stool use during treatment. This record can be very helpful in determining the effectiveness of a treatment.

Medical treatment of encopresis

Although many different treatment regimens have been developed for the treatment of encopresis, most of them are based on the following principles:

Empty the colon of stool
Establish regular soft and painless bowel movements
Maintain very regular bowel habits

Although chronic encopresis almost always has a significant behavioral component, behavioral therapy alone, such as rewards or discussion with the child, is usually ineffective. A combination of medical and behavioral therapy is likely to work best.

Emptying the stool from the colon and rectum is commonly referred to by healthcare professionals as evacuation or, in severe cases where the doctor has to manually remove the stool, stool removal. Evacuation can be carried out as follows:

Give an enema or series of enemas: The enema pushes fluid into the rectum. This softens the stool in the rectum and creates pressure in the rectum. This pressure causes the child to have a strong urge to have a bowel movement, and the stool usually passes quickly. The liquid in most enemas is water. Usually something is added so that the water is not absorbed by the intestinal mucosa. Commonly used enemas include commercial sodium phosphate preparations (such as Fleet or Pedia-Lax saline enemas), saline enemas, and mineral oil enemas. Daily enemas for several days may be necessary to completely evacuate the colon.
Give a suppository or series of suppositories: A suppository is a tablet or capsule that is inserted into the rectum. The suppository is made from a substance that can stimulate the rectum to contract and pass stool, or can soften the stool by drawing extra water from the body into the intestine. Popular stimulant suppositories include Dulcolax or Fleet Bisacodyl. Popular stool softener suppositories with glycerin are available from Fleet or Pedia-Lax. Daily suppositories for several days may be necessary for complete evacuation of the colon.
Give strong laxatives: Most laxatives work by increasing the amount of water in the colon. Some laxatives cause the secretion of water in the small intestine, while others reduce the amount of water absorbed in the small intestine. In both cases, the end result is significantly more water in the small intestine with the use of laxatives than without them. This large amount of water softens formed or hard stools in the intestines and causes diarrhea. Complete evacuation of the colon may require several days of treatment.

The establishment of regular soft and painless stools is mainly aimed at re-educating the child to give up the habit of holding stools. This is achieved by taking daily laxatives that cause loose stools. The laxative should be given in doses sufficient to induce loose stools once or twice a day. Loose stools pass easily and painlessly, prompting the child to have regular bowel movements rather than holding stools. See Medications for a list of commonly used laxatives. Remember that fecal retention and pollution go hand in hand. Thus, as long as the child keeps the feces in the rectum, the dirt will remain.

The last step is to work with the child to develop the habit of regular bowel movements. This step is just as important as the first two and should not be skipped just because the pollution has decreased after the previous steps.

Establish a regular time to use the toilet: the child should sit in the toilet for 5-10 minutes after breakfast and again after lunch EVERY DAY. Some families need to change their daily routine for this, but this is a very important step, especially for school-age children. Sitting on the toilet immediately after eating uses the "gastrocolic reflex" - bowel contractions that occur naturally after eating.
Behavioral techniques: Give your child age-appropriate positive reinforcement to develop the habit of going to the toilet regularly. For younger children, a chart with stars or stickers can be helpful. For older children, earning perks, such as extra time to watch TV or video games, can be helpful.
Training: Babies may respond to learning proper muscle use and other physical responses during bowel movements. This helps them learn to recognize the urge to defecate and defecate effectively.
Biofeedback: This technique has been successfully used to teach some children to make the best use of the abdominal, pelvic, and anal sphincter muscles they so often use to hold stool.

The duration of treatment for encopresis varies from child to child. Treatment should be continued until the child develops a regular and reliable bowel movement and the habit of holding the stool is gone. This usually takes at least a few months. It usually takes longer for young children than for older children.

Many parents are hesitant to give their children laxatives because they have heard that laxatives are harmful, cause more serious illness (such as colon cancer), or promote addiction. There is no conclusive evidence that any of this is true. Laxatives do not stop working if they are used every day for a long time.

In most cases, encopresis responds to the treatment regimen described above. If the contamination persists, your child's doctor may refer you to a digestive and intestinal specialist (pediatric gastroenterologist), a behavioral psychologist, or both.

Drugs for encopresis

Enemas: The use of enemas for encopresis is described above. The effectiveness of one or another enema preparation probably depends more on the volume (size) of the enema than on its chemical composition. The sodium phosphate enema is probably the most widely used type.

Note: Some gastrointestinal specialists do not recommend the use of enemas and suppositories or any anal procedures, as the child associates fear and pain with the anal area. The child may resist or feel additional trauma when performing such manipulations. After all, any tainted stool can be dissolved or rendered innocuous with medication taken by mouth.

Osmotic laxatives: These laxatives contain agents that are not absorbed effectively by the intestinal mucosa. This leads to a lot of excess water in the intestines, which softens the stool. Since all osmotic laxatives work by increasing the amount of water in the colon, it is important that your child drink plenty of fluids while taking one of these laxatives. Like any medicine, they should only be given as directed by your child's doctor. If the laxative does not seem to be working, do not increase the dose without talking to your child's doctor. Rarely, these products interfere with other medicines your child is taking.
Magnesium hydroxide. In addition to fluid retention in the intestines, this laxative promotes the release of a hormone that stimulates the movement of stools in the intestines. Some children suffer from abdominal cramps. This laxative is tasteless but has a thick, chalky texture that may be more palatable when mixed with a liquid such as milk or chocolate milk. It should be avoided in children with kidney problems.
Lactulose. This laxative is generally very well tolerated and has a sweet taste. In normal doses, it can cause gas and abdominal cramps.
Polyethylene glycol powder. It may pose a lower risk of dehydration or electrolyte imbalance than other osmotic laxatives. The powder is mixed with 240 ml of water, juice, soda, coffee or tea. The usual dose is 17 grams of powder per day (fill up to the measuring mark in the vial cap). This laxative is tasteless and odorless and is generally fairly easy to take. It may take a little longer than other products.
Sorbitol - This indigestible sugar has a rather sweet taste. This often causes gas and abdominal cramps.
Magnesium citrate – It works by the same mechanism as magnesium hydroxide and should not be used if kidney disease is suspected. The product is clear (not chalky like magnesium hydroxide) and can be refrigerated for better palatability.
Balanced electrolyte solutions with polyethylene glycol. These balanced electrolyte solutions are based on the same ingredients as Miralax but are used for complete colon cleansing in preparation for colonoscopy or abdominal surgery. They require you to drink plenty of fluids, which can taste better chilled. This laxative may be associated with nausea, bloating, abdominal cramps, and vomiting.
Emollient laxatives: These products reduce the absorption of water from the colon and thus soften the stool, making it easier to evacuate.
Mineral oil, milkinol. This laxative is practically tasteless and has an oily consistency. It may taste better if it is cold or mixed with a liquid such as orange juice. This can cause orange oil to come out of the anus, which causes itching and stains underwear. This laxative should generally not be taken with meals.
Stimulant laxatives: These drugs have a direct effect on the lining of the intestinal wall. They increase the secretion of water and salts in the colon and irritate the intestinal mucosa, causing contractions.
Sennosides: It is a laxative derived from a plant that stimulates the secretion of salt and water in the colon and promotes the movement of stool through the colon. It is used rarely and under close supervision in children. It may cause abdominal cramps at higher doses.
Bisacodyl: It is a colorless, odorless compound that enhances muscle contractions in the colon and stimulates the secretion of salt and water. It can be taken orally or as a suppository, and at higher doses it can cause abdominal cramps. It is also used rarely and under close supervision in children.
Dioctyl sodium sulphosuccinate: It is a cleanser that mimics the secretion of salt and water in the colon and promotes the movement of stool through the colon. It may cause abdominal cramps at higher doses.

Other treatments for encopresis

For encopresis, fiber supplements and certain foods, such as fruit juices and prunes, can have a laxative effect. These foods and juices act as osmotic laxatives. All of them contain various sugars that are inefficiently absorbed by the intestinal mucosa, thereby increasing the amount of water in the colon. In large enough doses, all these foods and juices are very effective laxatives. All children should be given fruits and vegetables to control weight and prevent constipation. However, most children do not want to consume enough of these foods each day for many months to be the primary treatment for encopresis. When consumed in sufficient quantities to provide soft stools twice a day, these foods and juices can cause bloating and gas.

Drinking plenty of fluids helps keep stools soft and may help prevent constipation in the first place.

Children with encopresis rarely need surgery. However, surgery may be used in extremely chronic cases and cases that do not respond to treatment.

Follow-up treatment for encopresis

The amount of follow-up needed for encopresis depends on the situation. Your child's doctor will probably want to see your child at least once after starting treatment to make sure the treatment is working or to change the treatment if necessary.

Prevention of encopresis

The best way to prevent encopresis is to prevent constipation in the first place. Make sure your child gets a varied diet with plenty of fruits and vegetables, whole grain breads and cereals. The child should drink water and other fluids frequently and be physically active every day. Lastly, make sure your child has a regular time each day to sit on the toilet. The best time to do this is after a meal.